Faculty Bibliography

In recent years, hemicrania continua has become a well-recognized primary headache disorder known for its chronicity and resulting disability in a subset of patients with headache. The core clinical features have been well described: unilateral, side-locked headaches that are continuous (although interrupted by frequent severe exacerbations), associated with autonomic symptoms and a response to indomethacin. However, areas of relative controversy remain in its classification and diagnosis. Several relatively large case series have better delineated the associated features of this disorder, including atypical presentations. Recently, neuroimaging research has provided new insights into the underlying pathways involved in the disorder, in particular activation of the contralateral posterior hypothalamus and the ipsilateral dorsal rostral pons. Despite its well-known response to indomethacin, many patients still endure long delays in the appropriate diagnosis and treatment. There remains a need for new treatments given the morbidity associated with long-term indomethacin use.

OBJECTIVE: Cognitive therapy (CT) has considerable utility for psychosomatic medicine (PM) in acute medical settings but, to date, no such cohesive adaptation has been developed. Part I delineated a CT model for acute medical settings focusing on assessment and formulation. In Part II, we review how CT can be applied to common PM clinical challenges. A pragmatic approach is helpful because this review targets PM trainees and educators. METHODS: Narrative review is used to discuss the application of CT strategies to common challenges in acute medical settings. Treatment complexities and limitations associated with the PM setting are detailed. Exemplary dialogues are used to model techniques. RESULT: We present CT approaches to eight common scenarios: (1) distressed or hopeless patients; (2) patients expressing pivotal distorted cognitions/images; (3) patients who catastrophize; (4) patients who benefit from distraction and activation strategies; (5) panic and anxiety; (6) suicidal patients; (7) patients who are stuck and helpless; (8) inhibited patients. Limitations are discussed. SIGNIFICANCE OF RESULTS: A CT informed PM assessment, formulation and early intervention with specific techniques offers a novel integrative framework for psychotherapy with the acutely medically ill. Future efforts should focus on dissemination, education of fellows and building research efficacy data.

BACKGROUND AND AIM OF THE STUDY: Aortic stenosis (AS) remains the most common valvular disease of the elderly in the United States. Though valve replacement has proven effective among older adults, decision-making regarding surgery is difficult for these patients and their physicians. Herein, the clinical outcomes and decision-making process for elderly patients with severe symptomatic AS was assessed. METHODS: A retrospective cohort study of patients aged > or = 60 years with severe AS was conducted at two large urban teaching hospitals. Severe AS was defined by a mean valve gradient > or = 50 mmHg or valve area < 0.8 cm2 by echocardiogram, and associated symptoms (angina, congestive heart failure, dyspnea, fatigue, or exercise intolerance). Demographic and clinical data and information about decision-making were obtained from inpatient and outpatient medical records. RESULTS: Of the 124 patients studied, 49 (39.5%) had aortic valve replacement (AVR) surgery. In a logistic regression analysis adjusting for gender, comorbidity and baseline functional status, those patients aged < 80 years were significantly more likely to have surgery than older patients. Surgery was associated with a large reduction in mortality in all age groups. At one-year follow up, 87.8% of all patients (87.5% of those aged > or = 80 years) who had undergone surgery were alive, while only 54.7% (49.1% of those aged > or = 80 years) who did not receive surgery were alive. Postoperative complications were similar among older and younger elderly patients. Comorbidity and age were the most common reasons for not offering elderly patients valve replacement. CONCLUSION: The results of the present study showed that AVR surgery improves the survival of elderly patients with severe AS, and patients aged > 80 years experience benefits similar to younger patients. Nevertheless, these findings suggest that surgery may not always be offered to elderly patients who might benefit from it.